A Convergent-mixed Method Study on the Attitudes and Perception Towards Suicide Memes and Suicidality

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INTRODUCTION
Through the technological progress of our society and the rise of social media, the increase in number of reported cases of depression soar [1].In the World Health Organization [2] report, the age-standardized suicide rate in the Philippines is 5.8 for males, 1.9 for females, and 3.8 for both sexes.The rate is established from the number of cases affecting a sample size of 100,00 people.According to the WHO, suicide is the second leading cause of death among 15 to 29-year-olds, and 78 percent of global suicides occur in low and middle-income countries.Furthermore, an alarming number of adolescents and young adults reported anxiety, depression, and some form of mental illness [3][4][5].
Additionally, the increase in mental illness is, at least in part, linked to the upturn in social media use among adolescents [6].It was found that the younger generations are the most active users of social media and have more tendency toward mental health problems [7].Furthermore, a study shows that the prevalence of mental health problems was positively associated with the frequency of social media exposure [8].Adolescents also perceive social media use as a threat to their mental wellbeing for the following reasons: (1) it causes mood and anxiety disorders; and (2) it is a platform for cyberbullying [9].
Social media is now being utilized to understand mental well-being, wherein computer scientists are using quantitative techniques to predict depression, suicidality, and anxiety [10].However, despite the increase of research in this field, it was found that the studies lack construct validity and lack reflection used to define and identify mental health status.There is also an issue with biases in data collection methods, the management of consent, and selecting the proper analysis techniques [11].The majority of the studies on the relationship between the duration of consumption of social media and mental health issues were done through cross-sectional research that lacks examining individual change over time.Balsamo et al. presented biases in data collection methods, which include the limitation in gathering clinically diagnosed samples and the possibility of social desirability in answering the research instruments [12].
An 8-year longitudinal study shows that the increase in time spent on social media was not associated with mental health issues when examined at an individual level [13].
Another study shows a relationship between the time spent on social media and the number of engagements on the different social media platforms and the symptoms of depression and anxiety [14].In essence, the study indicates that people are more likely to experience symptoms of anxiety and depression the more time they spend on social media.An increasing number of social media use was also related to online harassment, poor sleep, low self-esteem, and poor body image related to higher depressive symptoms [14].On the other hand, individuals who deactivated their Facebook account for a month reported lower depression and anxiety, as well as increases in happiness and life satisfaction [15].Furthermore, it was found that social media use does not predict impairment of mental health functioning, wherein vague booking (posting unclear but alarming posts to get attention) was found to predict suicidal ideation [16].
A study explored the value of social media for mental health awareness.The result shows that adolescents view social media as (1) its potential to promote positive mental health; (2) its utilization to seek information about mental health; and (3) there are both benefits and challenges to using social media in this manner [17].However, mental health stigma and trivialization are still common on social media [18].Some people with suicidal ideation go to online social media to share their personal experiences and communicate with others to get advice, support, or empathy from other users [19].This rise of unsolicited communications among online communities with the same mental health concerns is referred to as peer-to-peer support [20].
The current study explores the investigation of the relationship between internet content and users who engage in suicidal behavior in online spaces.It seeks to comprehend the dynamics and effects of online interactions on this particular demographic.Examining the digital landscape, the study aims to provide possible insights into how people struggling with suicidal thoughts may be influenced by online content.With the high sensitivity of this subject matter on ethical consideration, there has been a minimal number of studies to understand better the phenomenon of suicidality [21].A study of people with non-suicidal self-injury (NSSI) shows that these people go online to establish a sense of connection with other people with the same experience [22].This behavior is done to gather more social support online.However, mental health professionals also view this as a reinforcement of suicidal behaviors.In addition, it was also seen that the longer time spent on social networking websites leads to higher psychological distress and increased suicide ideation [23].
Even though the number of suicide memes is proliferating, there are minimal studies regarding the interaction between these two variables.In the context of the hypotheses of imitation of suicidal behavior, the effects of the mass media as transmitters of models for imitation have to be discussed.However, the possible influences of mass media have been a particular source of controversy.From a psychological point of view, the expression and the theory of imitation are deemed appropriate.The use of this theoretical framework makes it easier to explain some results concerning imitative behavior in suicidology.The majority of the papers published on this matter revolve around theoretical methodologies and least on empirical methods.
This paper aims to explore the interaction between suicide memes and suicidality among Filipino internet users.The study's relevance stems from its examination of the complex connection between users of digital spaces who engage in suicidal behavior and online content.Comprehending the effects of digital interactions on this population is essential for online community well-being.Furthermore, the study fills a vacuum in the literature by illuminating a delicate subject that has received little attention.Interventions and support networks for people dealing with suicidality in the digital age can benefit from this knowledge.Specifically, this study aims to answer the following questions: 1. What is the suicidal profile of the respondents?2. What are the suicide behaviors and attitudes of the respondents towards suicide memes? 3. Is there a significant difference in the attitude towards suicide memes between the intensity of suicidal behavior?
4. What are the respondents' perceptions of suicide memes? 5. Based on the results of both qualitative and quantitative studies, what results can be integrated?

Research Design
The researchers used a convergent mixed method in this study, which utilized qualitative and quantitative methods to address the interaction [24] between suicide memes and suicidality.The quantitative part of the study used the Columbia Suicide Severity Rating Scale (C-SSRS), a questionnaire used for suicide assessment, whereas, for the qualitative part, the researchers imposed three questions regarding the attitude of the respondents towards suicide memes.The results of the two instruments were analyzed separately and then integrated into one integrated result.

Instrumentation
For the quantitative part, the researcher used the Columbia Suicide Severity Rating Scale (C-SSRS) developed by multiple institutions, including Columbia University, with NIMH support.Questions were constructed for interview format use but could also be accomplished as a self-report measure.It has four constructs: severity of ideation, the intensity of ideation, behavior, and lethality [25].The validity of the instrument was tested through convergent validity with the Scale for Suicide Ideation (r=0.52,p<0.001; effect size=1.22,N=472) and Beck's Depression Inventory (r=0.80,p<0.001; effect size=2.66).For its internal consistency, the intensity of the subscale was high (α=0.937).
Furthermore, the researchers included four questions regarding the attitude of the respondents towards suicide memes.A thorough process of literature review, expert consultation, and pilot testing was used to select the qualitative questions that would gauge the respondents' attitudes regarding suicide memes.The preliminary inquiries were formulated by drawing upon existing literature pertaining to mental health and internet culture.After receiving input from mental health professionals and subject matter experts.Following are the guide questions employed by the researchers.
1. How often do you see memes about suicide? 2. How do you feel about it?
3. What are your thoughts about it?
4. How does it affect you?

Data Gathering Procedure
Due to the limitations of face-to-face interaction caused by the COVID-19 pandemic, the researchers gathered the data through an online form and posted it on various social media sites from September 2020 to March 2021.The researchers secured ethical clearance from their institution.Afterward, the researchers asked for permission from the C-SSRS authors to use their instruments for this study.The C-SSRS authors sent training videos to the researchers before providing the full copy of the instrument.

Description of Respondents
Table 1 presents the description of the respondents.Most of the respondents are 19-20 years old (60.87%), females (66.09%), and college-level (73.91%).The range of demographic profiles of the respondents was due to the non-limited data-gathering procedures.In order to achieve sufficient statistical power to identify significant relationships, the resources available for data collection and analysis are balanced, and a thorough grasp of the research topic within realistic constraints are guaranteed, the study's sample size of 230 respondents was chosen.

Data Analysis
The researchers utilized IBM Statistical Package for Social Sciences ver. 25 for the statistical analysis.The researcher analyzed the quantitative part of the C-SSRS by getting the frequency percentages of the responses per subscale.In order to examine the respondents' suicidality profile, including their attitudes towards suicide memes and their suicide behaviors, this study used frequency distribution and percentage.Furthermore, the Kruskal-Wallis test was employed to evaluate the variations in the degree of suicide behavior and attitudes towards suicide memes among different groups.
Furthermore, a categorical response format was used to gauge respondents' attitudes toward suicide memes; options included "It is Fun," "Triggered," "Offended," and "Nothing."This approach captures a variety of attitudes and is consistent with the study's objective of understanding how people view and react to suicide memes.In addition to making data collection easier, this categorical measurement enables a more in-depth examination of attitudes within the sample.
Whereas, for the qualitative part of the C-SSRS, the researcher used thematic analysis to summarize the responses.Furthermore, thematic analyses were also utilized to explore the attitudes of the respondents towards suicide memes.Finally, the researcher integrated the two instruments' results to compare the attitudes toward suicide memes among the responses in the C-SSRS.
Several steps were taken to reduce the possibility of bias in this study.These included using a mixed-method approach to provide a thorough knowledge of attitudes, guaranteeing anonymity to encourage honest responses, and selecting a representative and diverse sample of respondents.Furthermore, measures were taken to reduce the impact on researchers during the process of gathering and analyzing data, and any possible conflicts of interest were duly declared and handled.

RESULTS
Table 2 presents the suicidality profile of the respondents based on suicidal and self-injury behavior, suicide ideation, activating events, and treatment history.Based on the data, most of the respondents have selfinjury behavior without suicide intent (53.9%), wish to be dead (57%) and suicidal thoughts (53.5%), are experiencing current or pending isolation or feeling alone (69.6%) and did not receive any treatment (80%).Table 3 presents the percentages between suicide behaviors and the attitude toward suicide memes of the respondents within one month and a lifetime.Results show that the majority of the respondents deemed suicide memes as either fun or nothing.More respondents reported having suicidality (lifetime, within one month) and also perceived suicide memes as fun: Wished to be Dead (37.80%, 37.00%), Thoughts of Killing Oneself (33.90%, 39.60%), Thinking About Detailed Process of Killing Oneself (32.60%, 22.90%), and Intention to Commit suicide (28.30%, 7.40%).Those respondents who reported the absence of suicidal behavior show that the majority deemed suicide memes as fun or had no significant differences in their attitudes.
Table 4 shows the test of difference in the intensity of suicidal behavior between their attitude towards suicide memes.The purpose of this analysis is to determine whether attitudes toward suicide memes and the degree of suicidal behavior vary significantly between groups.Finding patterns in intensity can give important information about how to modify interventions and support programs.The result shows no significant difference among respondents with lifetime suicide behavior (p=0.194) and one-month suicide behavior (p=0.053).

Perception Towards Suicide Memes
Respondents were asked about their perception of suicide memes.Emerging themes were found: Funny, Inappropriate, Relating, Triggering, Destigmatizing, and Depending on Delivery/Poster.The researchers ended the data gathering at 230 respondents due to data saturation.

Funny
Respondents find suicide memes as funny and entertaining.They attribute this to the absurdity of the reality of life.People often find humor in absurdism, in which the cosmic meaninglessness that the society is trying to resolve depression at the same time living with the same ascribed meanings [26].Humor became an appealing tool in the struggle to raise awareness about the experiences of minorities [27].Examples of responses are as follows: "Making fun of something you are depressed about is like an escape.It is funny how I relate to it.""They're funny to me right now, especially the ones about absurd plans, like, for example, the fork in the socket.""I have the tendency to laugh at my distress and despair, so I find them funny."

Inappropriate
Some of the respondents also deemed suicide memes as inappropriate content to be posted on social media.According to the respondents, "Memes about suicide are mostly insensitive."Some social media posts are demanding triggers that increase the chance of insensitive and contextually inappropriate posts that damage impressions [28].Those who see suicide memes as inappropriate are those people who are trying to raise mental health awareness.Thus, spreading suicide memes was perceived as interfering with their efforts to reach inclusivity in our society.Some of the responses are as follows: "I always see 'haha' reactions in any suicide memes online.I guess people still do not understand the idea of suicide.""I think suicide memes are very insensitive and inappropriate in any situation.Besides, suicide is never a joke.We are living in a world where mental health conditions are being acknowledged more than before.That is why the existence of these kinds of memes is not helping at all." "I think that it is inappropriate to do such things, especially without a trigger warning.Moreover, memes are commonly used for fun, so others might get affected upon seeing that."

Relating
In addition, some of the respondents also reported that they could relate their current feelings to the suicide memes that they see on social media sites.This feeling of relatedness provides comfort to the suicidal feelings that they are experiencing.Aside from the feelings of depression, it was also reported that respondents could relate to the actions depicted on suicide memes as they have done it before.Memes have been one of the most prevalent modes of communication globally that are sometimes used to raise social and political issues [29].It is used to communicate, interact, and express ideas [30]; thus, suicide memes are used as communication among people with the same experiences.Some of the statements are as follows: "I relate myself to those memes because I have attempted it before.""It makes me feel comfortable and not feel alone since I can relate, and some people can relate to it.""It helps me.Humor, I believe that it alleviates the pain and makes me feel that I am not alone.Someone can relate too."

Triggering
Another theme collected among the responses is suicide memes as a form of trigger for those who are experiencing suicidal behaviors.Suicide memes are perceived as a process of making fun of those people who are experiencing it.Furthermore, it is also perceived as a reinforcing factor to commit suicide.There are limited studies regarding this matter; thus, the need for more interest in this field should be reinforced.Following are some of the statements regarding this theme: "Netizens should be sensitive enough with the memes they post, especially some of the social media users are under depression, and the idea of the meme might trigger some.""Those memes are definitely insensitive.Though some might be for entertainment purposes, people who had posted it should have been more cautious of doing it.Not everyone on social media is looking for entertaining memes.Others might be visiting social media sites for signs that they should commit suicide, and hopefully, not one of those were seen by them, which may add to the problem.""As someone who is experienced being suicidal and not being taken seriously for it, it could be a push for someone who is on the edge of making a suicide attempt because being made fun of for something serious and heavy could make a person feel worthless and helpless."

Destigmatizing
Another interesting theme is that the suicide meme is perceived as a tool to destigmatize suicide and depression.With the rise of mental health awareness, there have been various efforts by mental health professionals and mental health advocates to educate people regarding this matter.It comes in many forms, such as seminars, infographics, and social media postings (including suicide memes).All of which have their target audiences.Internet memes reflect cultural change [31]; thus, we can assess the current state of our society by exploring the emerging internet memes.Following are some of the statements: "Whenever I see memes about suicide, I always remember that there are other people who feel the same as me.Some people also struggle to live in this world.That even though they make it fun, deep inside, we are struggling to keep up in this society.""Maybe some social media influencers or pages just want this to be talked about publicly to prevent and have more knowledge for non-suicidal persons." "From what I commonly see, most suicide memes highlight the thought but not the act.Somehow, it opens a conversation.""It is like a normal meme.I think it helps to spread awareness to people without having an uneasy feeling."

Depends on Delivery/Poster
Despite the ambivalence of perception among the respondents regarding the suicide memes, some of the respondents created criteria on whether or not they would be offended by these memes.Based on their responses, it depends on who the poster is.If the poster seems to know and understand the nature of suicidality, it is perceived to spread awareness.However, if the poster lacks awareness regarding mental health, the viewers perceive it as a form of mockery.Furthermore, it is also acceptable if the meme is created in a relatable delivery.Following are some of the statements: "When the meme comes from a 'relatable' perspective, I tend to laugh with it.However, when it comes from someone who may not truly understand the subject, I find it quite offensive and insensitive.""It merely depends on how the meme was created.Nevertheless, often, I'm fine with it.""There are suicide memes that are actually fun (especially when the meme is so accurate to yourself or you kinda relate) to know that you are not the only one who finds it funny.However, on the other hand, when a nonsuicidal person makes it for fame or attention, I really do not like it.They do not know how it feels, yet they comfortably promote that mental health illness is defined as 'craziness.'They are making fun of someone who is suicidal or posting suicide photos and make it a meme-that is where the trigger starts."

Mixed-method Findings
Following are the results of converging the qualitative and quantitative results.The researcher selected some questions from C-SSRS and integrated the results into the perception of suicide memes of the respondents to test whether the people who have present suicidal behavior have negative perceptions of suicide memes.Note that some responses elicited more than one theme.This results in different percentage computations.
Table 5 shows the integration of suicidal behaviors and perceptions toward suicide memes.The result shows that negative perception (triggered, inappropriate, and offended) comes from the respondents who do not wish to be dead.At the same time, those respondents who have suicidal ideation deem suicide memes as either funny or relating.Furthermore, regardless of whether or not the respondents manifest thoughts of killing themselves, detailed plans on committing suicide, and intention to kill themselves, the majority still perceived suicide memes as funny and relating.

DISCUSSION
Social media sites have become a significant way to communicate.The ties between internet communication about suicide and the ability of social media to create social bonds can be perceived as intermediary ties that can be collaborated to reduce the risk of self-harm [32].The meaning of literary humor depends on the reading process of how well the readers engage with these texts, a process facilitated by schemata [33].
The researchers observed on social media sites that social media users have different perceptions towards suicide memes.Thus, the researchers assumed that those who keep on criticizing suicide memes are people without personal experiences of suicidality or did not/have limited encounters with any suicidal person during their lifetime.There is still some misconception manifesting in our society towards suicidality.Aside from suicide memes, people also perceived songs with suicide content to be triggering.However, an experiment was done where they concluded that this type of music primes implicit cognitions related to suicide, but it does not affect variables associated with increased suicide risk, such as effect, attitudes, and perceptions [34].The researchers believe that regardless of the person's exposure with suicidality to suicide memes, their suicidality remains unchanged.
Common myths about suicide still prevail, such as whether people who talk about suicide will commit it if there is a risk that elicits suicidal thoughts if talked about, if suicide happens without previous warning or if it cannot be prevented if a person has already made up their mind to do it [35].There are still plenty of highly cautious people to tackle suicide, especially in public, due to their understanding that it can reinforce the suicidal risk of other people.This is one of the reasons why people condemn the posting of suicide memes.However, another research suggests that talking about suicide and acknowledging its existence reduces, rather than increases, suicidal ideation and results in improvements in mental health [36].This is in line with the result wherein some respondents perceived suicide memes as destigmatizing and addressed the issue by being a catalyst to initiate a conversation regarding this issue.
The findings of this study have important applications for a range of stakeholders.A deeper understanding of how people with varying degrees of suicidality perceive and engage with suicide-related content on the internet can be beneficial for mental health practitioners.The creation of specialized interventions and risk-aware support plans can be influenced by this knowledge.Social media companies and content producers also need to think about how suicide memes might affect people who are already at risk.Enforcing content guidelines and offering mental health support resources can be vital in fostering a safer online community.Additionally, by using these insights, parents and educators can have candid discussions about mental health and the consumption of online content, giving people-especially young people-the skills necessary to assess and react appropriately to sensitive content.All things considered, this study provides practical insights that can lead to better-informed and successful strategies for addressing suicidality in the digital age.

CONCLUSION
The researcher, therefore, concludes that suicide memes should not be perceived as triggering and offensive but rather should be perceived as a creative way to address the issue of suicidality.However, we cannot deny the sensitivity of the topic that there are situations in these suicide memes delivered mockingly.Thus, the researchers recommend further research on the appropriateness of delivery of suicide memes to utilize this spreading awareness more appropriately.

HUMAN AND ANIMAL GUIDELINES
No animals were used in this research.All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committees and with the 1975 Declaration of Helsinki, as revised in 2013.

CONSENT FOR PUBLICATION
Written informed consent has been taken from all the respondents to this study.

STANDARDS OF REPORTING
STROBE guidelines were followed.
this study was obtained from the University Research Ethics Board at the Office of the Vice President for Research, Extension, Planning, and Development, affiliated with Polytechnic University of the Philippines.